1. Q4: Clinical Case Conference on Human Immunodeficiency Virus Chua, Kathleen S.

2. 4. ENUMERATE RHEUMATIC CONDITIONS FOUND IN HIV-INFECTED INDIVIDUALS Clinical Case Conference on Human Immunodeficiency Virus

3. U. A. Walker, A. Tyndall and T. Daikeler Rheumatic conditions in human immuno- deficiency virus infection Rheumatology 2008;47:952–959

4. Rheumatic conditions found in HIV- infected individuals HIV-associated arthritis – Nonerosive-oligoarthritis of the legs of unknown etiology – Found in up to 1% of patients – Usually self-limited and lasts less than 6 weeks Reiter's syndrome (reactive arthritis) – common in persons with HIV infection who are HLA-B27 positive – best treatment is HIV suppression and tumor necrosis factor (TNF)-alpha antagonists. Septic arthritis – major joints affected are the sternoclavicular and leg joints. U. A. Walker, A. Tyndall and T. Daikeler Rheumatic conditions in human immuno- deficiency virus infection Rheumatology 2008;47:952–959

5. Rheumatic conditions found in HIV- infected individuals Indinavir-associated hyperuricemia and arthralgia: – Indinavir has been implicated in HIV, but crystals were not detected. Gout: – Hyperuricemia is common with HIV – Ritonavir boosting has been implicated Rhabdomyolysis: – May complicate primary HIV infection or complicate statin use in patients receiving highly active antiretroviral therapy (HAART) U. A. Walker, A. Tyndall and T. Daikeler Rheumatic conditions in human immuno- deficiency virus infection Rheumatology 2008;47:952–959

6. HIV-associated polymyositis: – Polymyositis has been reported in as many as 2% to 7% of persons with HIV infection – Muscle biopsy shows CD8 cell infiltrates and viral antigen. – HIV-associated polymyositis has been reported to be clinically and histologically identical to idiopathic polymyositis, but has a good prognosis and responds well to immunosuppressive treatment. Zidovudine myopathy: – seen exclusively with zidovudine – characterized by muscle weakness and normal or slightly elevated creatine kinase levels – Electron microscopy shows abnormal mitochondria that resolves with drug discontinuation. Vasculitis: – This is described in early HIV disease in patients with high CD4 counts, as well as later in patients with severe immunosuppression. – Biopsies show nonspecific neutrophilic or monocytic vascular inflammation and often other clinical features, such as rash or peripheral neuropathy or both. – Some patients have cryoglobulinemia – Some have HIV-associated polyarteritis nodosa – Some have large-vessel complications, including aneurysms or strokes. U. A. Walker, A. Tyndall and T. Daikeler Rheumatic conditions in human immuno- deficiency virus infection Rheumatology 2008;47:952–959

7. Diffuse infiltrative lymphocytosis syndrome: – Prevalence in the HIV population is approximately 3%. – Present with bilateral painless parotid gland enlargement, lacrimal gland enlargement, and sicca symptoms – The pathogenesis is thought to be an excessive response to HIV with CD8 lymphocytosis, and it may be associated with lymphoid interstitial pneumonia in up to 31%, or involvement of muscles or liver. – HAART appears to be effective given that the incidence is decreasing Systemic lupus erythematosus: – This condition usually improves in patients with untreated HIV infection, which fits the current concepts of the importance of CD4 cells in pathogenesis. – However, this can also be a component of immune reconstitution inflammatory syndrome. – Systemic lupus erythematosus may also be the source of a false-positive screening test for HIV, but not the confirmatory Western blot. Sarcoidosis: – When sarcoidosis coexists with HIV, most patients who are symptomatic have CD4 counts exceeding 200 cells/µL, which is consistent with the current concept of the role of CD4 cell lymphocytes in the pathogenesis of granuloma formation. – At present, most patients with active sarcoidosis have this as a result of immune reconstitution inflammatory syndrome. U. A. Walker, A. Tyndall and T. Daikeler Rheumatic conditions in human immuno- deficiency virus infection Rheumatology 2008;47:952–959